Clinical Documentation Integrity Specialist I

Inspire health. Serve with compassion. Be the difference.

Job Summary

Accountabilities

• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation. (60%)

• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (25%)

• Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. (10%)

• Develop and maintain supportive, collaborative relationships with providers and health care team members to include education and follow up. (2%)

• Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies. (1%)

• Serve as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.) (1%)

• Assign a working DRG for health care team discharge planning and CDI use. (1%)

• Performs other duties as assigne

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Associate degree - Nursing, Health Information Management, or related field

• 2 years - Adult medical/surgical/critical care/ER/PACU nursing coding or related field

In Lieu Of

• In Lieu of the education and experience requirements noted above, the following combination of education, training and/or experience will be considered an equivalent substitution: MD/DO/PA/NP

Required Certifications, Registrations, Licenses

• RN/RHIA/RHIT/CCS/CIC/Licensure in related field

Knowledge, Skills and Abilities

• Computer skills, keyboarding.

• Strong communication skills with ability to interact with providers and remain tactful.

• General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems. Preferred

Work Shift

Location

Facility

Department

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